City, State, ZIP Code

Name______Address______

Postmaster Date______City, State, ZIP Code

Request for Change of Address or Boxholder Information Needed for Service of Legal Process

Please furnish the new address or the name and street address (if a boxholder) for the following: Name: ______Address: ______NOTE: The name and last know address are required for change of address information. The name, if known, and post office box address are required for boxholder information.

The following information is provided in accordance with 39 CFR 265.6(d)(6)(ii). There is no fee for providing boxholder information. The fee for providing change of address information is waived in accordance with 39 CFR 265.6(d)(1) and (2) and corresponding Administrative Support Manual 352.44a and b. - Capacity of requester (e.g., process server, attorney, party representing himself): ______- Statute or regulation that empowers me to serve process (not required when requester is an attorney or a party citing pro se – except a corporation acting pro se must cite statute: ______- The names of all known parties to the litigation: ______- The court in which the case has been or will be heard: ______- The docket or other identifying number if one has been issued: ______- The capacity in which this individual is to be served (e.g. defendant or witness): ______WARNING THE SUBMISSION OF FALSE INFORMATION TO OBTAIN AND USE CHANGE OR ADDRESS INFORMATION OR BOXHOLDER INFORMATION FOR ANY PURPOSE OTHER THAN THE SERVICE OF LEGAL PROCESS IN CONNECTION WITH ACTUAL OR PROSPECTIVE LITIGATION COULD RESULT IN CRIMINAL PENALTIES INCLUDING A FINE OF UP TO $10,000 OR IMPRISONMENT OR (2) TO AVOID PAYMENT OF THE FEE FOR CHANGE OF ADDRESS INFORMATION OF NOT MORE THAN 5 YEARS, OR BOTH (TITLE 18 U.S.C. SECTION 1001). I certify that the above information is true and the address information is needed and will be used solely for the service of legal process in connection with actual or prospective litigation. ______Printed Name Signature ______Address FOR POST OFFICE USE ONLY

___ No change of address order on file. BOXHOLDER’S POSTMARK ___ Not known at address given. Name: ______Moved, left no forwarding address. Street Address: ______No such address ______